Images in Clinical Medicine

Perforated Duodenal Ulcer

Ernesto P. Molmenti, M.D.

N Engl J Med 1997; 336:1499May 22, 1997

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Figure 1 A 48-year-old man who was receiving medical treatment for peptic ulcer disease experienced intense epigastric pain, sudden in onset and without emesis, four hours before admission. On examination, he had rigidity of the abdominal muscles in the epigastrium and tympanicity on percussion in the right upper quadrant. A chest film (Panel A) showed bilateral pneumoperitoneum (arrows). An exploratory laparotomy revealed a perforated duodenal ulcer with callous borders (Panel B). The ulcer was closed with three stitches and an omental patch, and a parietal-cell vagotomy was performed. The patient had an uneventful postoperative course, with no recurrence. D denotes duodenum, and S stomach.

Ernesto P. Molmenti, M.D.
Thomas E. Starzl Transplantation Institute, Pittsburgh, PA 15213

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